VANCOUVER - Regional health authorities will receive up to $50 million annually over the next three years for targeted primary and community care programs to better support patients and their families.
The community-based programs will be tailored to local needs, with a focus on enhancing supports available for patients with complex chronic conditions, those with mental-health and substance-use challenges, and seniors with complex-care needs.
"Providing care to individuals in their home rather than hospital is one example of a suite of integrated primary and community care programs underway in health authorities to better support patients, their families and caregivers," said Health Minister Margaret MacDiarmid. "Keeping people out of acute and residential care also benefits the health system as these are often our most costly forms of care."
One example is the Home is Best program, which aims to help seniors, who otherwise would need residential care, live safely at home and avoid future hospital emergency admissions. The program specifically targets seniors waiting for a residential care bed, or residential care eligibility assessment.
The Home is Best program will be rolled out in all five health authorities. Under the program additional in-home care supports are tailored to an individual's needs. Home support care can include bathing and washing, dressing, grooming, taking medication and other personal care needs. The program was piloted in Vancouver Coastal Health's North Shore and in Fraser Health, and has shown positive results. In Vancouver Coastal Health, the program resulted in a 30 per cent decrease in acute care use, and a 25 per cent reduction in emergency department visits.
"Older adults have told us that they prefer to be cared for at home, and evidence shows that when appropriately targeted and managed, care at home is safer and more effective while also helping to maintain an individual's independence," said Shannon Berg, executive director of Vancouver Coastal Health's home and community care program. "In addition, we have examples of patients whose ability to move around and continue such functional activities as sitting, lifting, and stair climbing have improved remarkably through being at home with enhanced support. The program also receives high levels of client satisfaction."
The program also provides benefits to family caregivers by ensuring their loved ones can remain safely at home with the required supports.
"When my grandfather was in the hospital, my grandmother said all she really wanted is for my grandfather to come home," said Richmond resident Vivian Lo. "Now he is at home, and while he needs a lot of attention, he's doing very well. We're so grateful for the Home First program."
"The Home is Best philosophy is what's right for patients and clients and in the process of doing the right thing for them, we also do the right thing for the health-care system," said Lynda Foley, executive director, Fraser Health's clinical programs and operations, home health and end of life. "Through Home First we've seen exciting results with fewer admissions to acute and residential care."
The accelerated integrated primary and community care programs will be launched or expanded by health authorities to meet local demand by front-line health professionals such as family physicians and integrated health-care teams. Examples range from expanding mental-health treatment in the community to better assessing seniors at risk from multiple chronic diseases to building care teams to support patients through an early discharge from acute care.
The ministry has allocated $36.4 million to date in 2012-13 to support health authority programs. Health authorities will have the opportunity to apply for funding for community programs for the remaining funds in the $50 million funding envelope, and will regularly report to the ministry on their progress.
The announcement builds upon investments the Ministry of Health is making in primary care programs. The government of British Columbia and the BC Medical Association are partnering to improve primary care services and ensure all B.C. citizens who want a family doctor are able to access one by 2015. For more information:
Two backgrounders follow.
Media Relations Manager
Ministry of Health
250 952-1887 (media line)
Strengthening primary and community care in B.C.
Regional health authorities will receive up to $50 million annually over the next three years for targeted primary and community care programs. To date, the ministry has allocated $36.4 million in 2012-13 to support health authority programs.
Below, presented by health authority, is a list of the targeted primary and community care programs and funding, that are being launched or expanded in 2012-13:
Fraser Health - $14.0 million
- The Psychosis Treatment Optimization Program oversees collaborative care for mental-health clients with psychosis in the community through a central psychosis clinic at the Royal Columbian Hospital and three mobile psychosis treatment teams that support the clients across the health region.
- Expand the BreatheWELL program from Burnaby and New Westminster to include Chilliwack and Langley. BreatheWELL is a home-based proactive intervention program for people with chronic obstructive pulmonary disease to manage and control symptoms, helping them to stay at home safely with a better quality of life.
- Community REDi unites outpatient rehabilitation and community reintegration programs, such as recreation centre exercise classes, education sessions and groups, to support early discharge of patients from a hospital setting to their homes. Ensuring there are links with a patient's community after rehabilitation helps individuals to self-manage their health conditions more effectively over time and enables people to remain in their homes longer. Community REDi is being delivered in Surrey, South Surrey and the Tri-Cities.
- End of Life Care Management program provides access and choice in location of death to patients and families with advanced life threatening illness. Enhanced Palliative Care at Home is a prototype in the Tri-Cities that will feature dedicated palliative services, including palliative focused nurses and the promotion of partnerships with family physicians, to support clients who are in their final months of life and those who wish to die at home.
- The Home First program provides health services seniors with complex care needs in their home and community setting. This would avoid transfers to residential care allowing the patient to stay in their home longer.
Interior Health - $3.7 million
- The Home First program provides health services for high-needs older adults in the home and community setting with a goal of avoiding transfers to residential care allowing patients to stay in their home longer.
- Integrate community mental health and substance use services with primary care ensures rural and remote parts in the Interior can better care for patients that have severe mental illness or problematic substance use.
- Leverage a community-based program called BreatheWell that is operating in other parts of the province to curb a growing number of patients with chronic obstructive pulmonary disease through prevention and better care management before they require acute care.
Northern Health - $2.1 million
- Northern Health will use a Home First philosophy to enable seniors with complex care needs, those with mental health and substance use and individuals with chronic disease in each prototype community to participate in their care and approaches to meeting their needs. Initially, Northern Health will focus on the implementation of intensive care management and coordination in the primary care home in three prototype communities - Prince George, Fort St. John and Fraser Lake. Building on what is learned, more communities will be added in subsequent years, with a goal of including all communities by 2014.
VIHA - $7.9 million
- Expand the Assertive Community Action team that supports severe and persistent mentally ill clients in central and northern part of Vancouver Island as part of seamless community care.
- Intensive Integrated Care Management approach works with primary care physicians to care for people in the Nanaimo /Oceanside area who have multiple long term conditions stay within their own community.
- The Home First program provides health services for high-needs older adults in the home and community setting. This will help avoid transfers to residential care allowing the patient to stay in their home longer.
Vancouver Coastal Health - $8.7 million
- Continue the Acute Home Based Treatment strategy that aims at providing home based treatment for mental health and substance use patients rather than going to a hospital. The funding will allow the program to expand its original team at Vancouver General Hospital and add additional teams at Richmond and Lions Gates Hospitals.
- Expand the Assertive Community Treatment team that works in the Down Town East Side or with clients originating from the area. The objective is to reach people with severe mental health and substance use issues who would not access health services through traditional entry points but rather just present in the emergency department.
- Support Seniors with care needs / Chronic Disease Community Transitions by expanding interdisciplinary teams to address the community transition needs of older adults over the age of 70 who are in need of care or have chronic disease diagnosis and typically frequent emergency departments.
- Fully implement Early Discharge Support for patients with chronic diseases from hospital with the support of an interdisciplinary community reintegration team.
- Implement a phased three-year Care Management Strategy to redesign home health services to integrate as part of primary care teams that each community works with general practitioners in the planning and development of the work.
- The Home First program provides health services for high-needs, older adults in the home and community setting. This would avoid transfers to residential care allowing the patient to stay in their home longer.
Media Relations Manager
Ministry of Health
250 952-1887 (media line)
Home is Best: caring for seniors in their home
Home is Best is being expanded or rolled out in all five regional health authorities through the government's accelerated integrated primary and community care strategy. Home is Best is an approach to care and service delivery, based on current evidence that: home is the best place for a person to live, as long as they are safely able to do so with appropriate supports in place; and, home is the best place to recover from illness once hospital care is no longer needed.
The goal is to support high-needs clients to live in their homes while waiting for residential care, to avoid residential care if possible, to avoid acute care use if not appropriate, and for end of life clients to allow for a supported home death if possible.
In Fraser Health, since July 2011:
- 445 clients with complex care needs who meet the criteria for residential care have been enrolled in Home First.
- More than 100 clients have been living at home, rather than in residential care, for over 12 months. These 100 clients have demonstrated a 69 per cent reduction in emergency department visits and a 50 per cent reduction in their acute care admissions since enrolment in the Home First.
- Clients have spent a cumulative 2,300 months receiving care in the community rather than residential or acute care.
- 968 seniors have been supported to return home from the emergency department and have avoided admissions to acute care.
- Short term home support hours have increased 36 per cent over 2011-12 levels to support these clients are home.
- Long term support hours have increased 14 per cent since 2011-12.
In Vancouver, since May 2011:
- In Vancouver Coastal Health from May 2011 to August 2012, a total of 251 clients received services through Home First.
- For these clients, the average hospitalization rate was reduced by 32 per cent (from 3.54 admissions/1,000 days to 2.40), and emergency visits were reduced by 27 per cent (from 5.59 ED visits/1,000 days to 4.08).
- Of the 251 clients, only 18 per cent (45 clients) were admitted to residential care after ending their Home is Best service, and these clients were able to make that choice in the familiar surroundings of their home.
- Also, eight per cent (20 clients) were able to be supported to die in their home setting.
Interior Health implemented the Home First program under the Home is Best philosophy starting in November 2012. Using lessons from both Vancouver Coastal Health and Fraser Health, standardized admission and assessment criteria, clients are now being brought on to the program where services are tailored to suit the needs of clients and their families through intensive care management and a community based team approach. New care teams have been established in four major communities to focus efforts on specific clients to delay or defer residential care admission and avoidable hospital admissions/visits.
VIHA implemented the Home First program at Royal Jubilee Hospital and Nanaimo Regional General Hospital in November 2012. The aim is to improve care and outcomes for seniors by providing enhanced support at home that would allow for earlier discharge from hospital. VIHA staff and physicians have been closely involved in the implementation of the program at the two sites. The Home First teams are comprised of home and community care clinicians, a nurse practitioner and a community-based pharmacist who works collaboratively to provide enhanced community services to support the transition of clients with complex needs from hospital to home, avoiding or delaying admission to residential care.
Northern Health has been building programs that put seniors and patients at the centre of the care team; and that has included projects such as enabling the elderly with care needs to remain in their community and home much longer. Home First is a philosophy that is a cornerstone in the work that Northern Health has been doing since September 2012 in three prototype communities: Fort St John, Fraser Lake and Prince George. At the heart of the work is ensuring the services function in harmony to provide the best possible care in the best possible place for all residents. System and patient journey mapping are identifying the solutions that will improve the health outcomes and overall health of the residents and seniors in the region.
Media Relations Manager
Ministry of Health
250 952-1887 (media line)